which of the following lab values should the nurse monitor for a patient receiving heparin therapy which of the following lab values should the nurse monitor for a patient receiving heparin therapy
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?

Correct answer: C

Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.

2. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.

3. Is the statement 'The metabolic rate is the highest after a few hours of sleep' true or false?

Correct answer: B

Rationale: The statement is false. The metabolic rate is actually lowest during sleep and increases upon waking. During sleep, the body conserves energy, leading to a lower metabolic rate. As the body wakes up and becomes active, the metabolic rate increases to support the body's functions and energy needs. Therefore, the metabolic rate is not the highest after a few hours of sleep, making the statement false.

4. A nurse is reviewing the medication administration record for a client who is 2 days postoperative following abdominal surgery. The nurse should recognize that which of the following medications places the client at risk for wound dehiscence?

Correct answer: C

Rationale: Prednisone is a corticosteroid that can impair wound healing and increase the risk of wound dehiscence.

5. A client with chronic osteomyelitis is being discharged from the hospital. What is the nurse’s priority discharge intervention?

Correct answer: C

Rationale: The correct answer is C: Teaching adherence to the antibiotic regimen. In chronic osteomyelitis, the priority is to ensure proper treatment of the infection, which heavily relies on consistent adherence to the prescribed antibiotic regimen. This helps in eradicating the infectious organisms and preventing recurrence. Choices A, B, and D are important aspects of care but teaching adherence to the antibiotic regimen takes precedence as it directly impacts the successful management of chronic osteomyelitis.

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